Primary care

BMJ: first published as 10.1136/bmj.331.7510.197 on 21 July 2005. Downloaded from http://www.bmj.com/ on 9 July 2022 by guest. Protected by copyright.
Factors associated with spousal physical violence in
Albania: cross sectional study
Genc Burazeri, Enver Roshi, Rachel Jewkes, Susanne Jordan, Vesna Bjegovic, Ulrich Laaser

Abstract 150 000 in 1991 to more than 500 000 a decade later.6 Department of
Public Health,
In the western Balkans there are substantial social and Faculty of Medicine,
Objective To describe the prevalence of intimate cultural differences between people from urban and University of
partner violence and associated factors among rural areas,5 giving rise to an expectation that place of Tirana, St “Dibres,”
married women in Albania. birth (and upbringing) could be an important determi-
N.371, Tirana,
Albania
Design Cross sectional study. nant of attitudes or social norms that might give rise to Genc Burazeri
Setting Tirana, the capital city of Albania. different behaviour patterns and practices.8 Albania lecturer in
Participants A representative sample of 1039 married has been described as a particularly patriarchal epidemiology and
women aged 25-65 living in Tirana and recorded in research methods
society.9 10 Enver Roshi
the 2001 census. Intimate partner violence is integrally linked to lecturer in
Methods Questionnaire on intimate partner violence ideas of male superiority over women.4 These are epidemiology and
and social and demographic characteristics of the research methods,
manifest in different ways in different societies, but vio- head of public health
women and their husbands. lence is usually used to create and enforce gender hier- department
Main outcome measure Women’s experience within archy and punish transgressions11–13; to resolve Gender and Health
the past year of being hit, slapped, kicked, or relationship conflict14; and to seek resolution of crisis of Research Unit,
otherwise physically hurt by the husband. masculinity by providing an (often transient) sense of
Medical Research
Council, Pretoria,
Results More than a third (37%, 384/1039) of women powerfulness.11–13 Different factors influence, and South Africa
had experienced violence. Risk was greatest among indicate, the status of women and men in a society and Rachel Jewkes
women aged 25-34 (odds ratio 1.47, 95% CI 1.04 to so influence these processes. These factors include director
2.09), women with tertiary education (3.70, 2.04 to social and demographic characteristics of the women Unit of Primary
6.67), women in white collar jobs (4.0, 1.59 to 10.0), and men, their economic circumstances, and the char-
Prevention of
Addiction, Federal
women with least educated husbands (5.01, 2.91 to acteristics of their relationship.15–20 Other factors, Centre for Health
8.64), and women married to men raised in rural including alcohol consumption, depression, experi- Education, Cologne,
areas (3.31, 2.29 to 4.80). Women were at higher risk if Germany
ence of abuse in childhood, and the strength of family Susanne Jordan
they were more educated than their husbands (4.76, and social networks, may additionally influence officer
2.56 to 9.09). responses to conflict and a perception of emotional School of Public
Conclusions In transitional Albania, the risk of insecurity.1 4 19 20 Health, School of
spousal violence is high, and more empowered This study aimed to describe the magnitude of the Medicine,
women are at greater risk. University of
problem of physical violence among intimate partners Belgrade, Serbia
in Tirana and the demographic and social factors asso- and Monte Negro
ciated with it. Vesna Bjegovic
Introduction professor of social
medicine, head of the
Intimate partner violence is present in almost all socie-
ties1 2 and is associated with considerable morbidity.1 3
Methods centre
Section of
Little is known about the magnitude of intimate We carried out a cross sectional study in Tirana in July- International Public
partner violence and the factors associated with it in October 2003. At the last census in April 2001, 93 230 Health, Faculty of
Health Sciences,
post-communist countries.1 Intimate partner violence women aged 23-63 (at that time) resided in Tirana.7 University of
is more common in patriarchal societies and settings The sampling frame for this study was the list of these Bielefeld, Germany
where violence is commonly used in conflict or to gain women’s names obtained from the National Institute of Ulrich Laaser
ascendance,4 so there has been particular concern Statistics. From this list we drew a simple random sam- professor of
international health
about its prevalence in patriarchal transitional coun- ple of 1500 women (both married and unmarried), but
Correspondence to:
tries, where violence has become commonplace and we included only married women, as cohabiting is G Burazeri
social relations have been disrupted.5 unusual in Albania. The study was conducted in 2003 gburazeri@
Albania is a small country, and 58% of the popula- so the women were aged 25-65. Of the 1500 potential yahoo.com
tion lives in rural areas.6 It has undergone major social respondents, 106 women could not be identified
BMJ 2005;331:197–201
and political upheaval in the past decade.5 6 After the (wrong address or changes of residence), 198 women
collapse of the communist regime in 1990 many peo- were excluded as they were not currently married, 129
ple migrated from rural to urban areas.6 7 The popula- women were either absent (after two visits), or refused
tion of Tirana, the capital city, increased rapidly from to participate, and 28 questionnaires were incomplete

BMJ VOLUME 331 23 JULY 2005 bmj.com 197

Primary care

Table 1 Prevalence of spousal physical abuse, Tirana, Albania. Values are numbers (percentages) unless stated otherwise
Experienced physical No physical
violence in past year violence in past year Odds ratio

BMJ: first published as 10.1136/bmj.331.7510.197 on 21 July 2005. Downloaded from http://www.bmj.com/ on 9 July 2022 by guest. Protected by copyright.
Wife’s (or family) characteristic No* (n=384) (n=655) (95%CI) P value
Age (years)
46-65 379 121 (31.5) 258 (39.4) 1.00†
35-45 314 112 (29.2) 202 (30.8) 1.18 (0.86 to 1.62) 0.30
25-34 346 151 (39.3) 195 (29.8) 1.65 (1.22 to 2.23) <0.01
Education
>12 years 271 131 (34.7) 140 (21.5) 1.00†
9-12 years 528 178 (47.2) 350 (53.7) 0.54 (0.40 to 0.73) <0.01
0-8 years 230 68 (18.0) 162 (24.8) 0.45 (0.31 to 0.65) <0.01
Employment status
White collar 276 130 (34.4) 146 (22.6) 1.00†
Housekeepers 133 47 (12.4) 86 (13.3) 0.61 (0.40 to 0.94) 0.02
Blue collar 334 105 (27.8) 229 (35.5) 0.51 (0.37 to 0.72) <0.01
Unemployed 280 96 (25.4) 184 (28.5) 0.59 (0.42 to 0.82) <0.01
Religion
Christian 423 161 (42.4) 262 (40.2) 1.00†
Muslim 609 219 (57.6) 390 (59.8) 0.91 (0.71 to 1.18) 0.49
Origin
Urban area (Tirana or other) 495 166 (44.4) 329 (51.4) 1.00†
Rural area (came to city before age 10) 318 126 (33.7) 192 (30.0) 1.30 (0.97 to 1.74) 0.08
Rural area (came to city at age ≥10) 201 82 (21.9) 119 (18.6) 1.37 (0.97 to 1.91) 0.07
Income
High (>150 €/capita/month) 153 61 (16.6) 92 (14.6) 1.00†
Middle (80-150 €/capita/month) 422 155 (42.2) 267 (42.2) 0.88 (0.60 to 1.28) 0.49
Low (<80 €/capita/month) 424 151 (41.1) 273 (43.2) 0.83 (0.57 to 1.22) 0.35
Educational discrepancy
Women more educated 176 105 (27.9) 71 (10.9) 1.00†
Both equally educated 743 249 (66.2) 494 (75.9) 0.34 (0.24 to 0.48) <0.01
Men more educated 108 22 (5.9) 86 (13.2) 0.17 (0.10 to 0.30) <0.01
Employment discrepancy
Wife only employed 29 17 (4.5) 12 (1.9) 1.00†
Both employed 581 218 (58.0) 363 (56.4) 0.42 (0.20 to 0.90) 0.03
Husband only employed 182 70 (18.6) 112 (17.4) 0.44 (0.20 to 0.98) 0.04
Both unemployed 228 71 (18.9) 157 (24.4) 0.32 (0.14 to 0.70) 0.01
Mean (95% CI) No of children 1034 2.28 (2.17 to 2.39) 2.09 (2.01 to 2.17) 0.01
Mean (95% CI) No of household members 1017 5.36 (5.21 to 5.51) 5.16 (5.04 to 5.28) 0.05
*Discrepancies in totals are due to missing values.
†Reference category.

and could not be included in the analysis, giving a
response rate of 87% (1039 of 1196).
A structured questionnaire was administered by an
interviewer to married women who agreed to
participate in the survey after an informed consent
form had been signed. The questionnaire included
questions on age, education, religion, occupation, place
of birth (rural or urban) and age of move to Tirana (if
any) of the woman and of her husband. It asked about
number of children, household size, and household
disposable income (from all sources, after rent is paid).
It asked about whether the husband was “violent and
constantly jealous,” was drunk (almost) every day, and
whether the woman knew if he had been abused by his
parents during childhood or had witnessed violence
between his parents. Women’s recent experience of
spousal violence was measured by a question asking
whether in the past year she had been “hit, slapped,
kicked, or physically hurt” by her husband. Those
answering “Yes” were asked how many times this had
happened.
We computed income per capita as the ratio of dis-
posable income per family member living in the home
(partner, children, parents, inlaws) and categorised as
low ( < €80 (£54; $95) per capita/month), middle
(€80-150 per capita/month), and high ( > €150 per
capita/month). Educational attainment of women and
their husbands was classified as high if they had a uni-
versity degree (or other post-school qualification), mid-
dle if they had a formal education of 9-12 years, and
low if formal education lasted no more than eight
years. For profession we used the self reported main
occupation, categorised as “white collar” (clerk or busi-
ness occupations), “blue collar” (industry and agricul-
ture), housekeeping (for women), or unemployed or
retired.
Data analysis
After calculating descriptive statistics for the preva-
lence of physical spousal violence and social and
demographic variables, we used logistic regression to
examine bivariate associations between these variables
and Student’s t test to compare the mean number of
children in a household and number of household
members in the two abuse categories. We then
constructed two multiple variable logistic regression
models. We first modelled factors associated with
reporting spousal violence for 945 women who had no
missing data, using a backwards stepwise elimination
procedure with a P value to exit > 0.10. The model
tested the age of the husband, age difference between
spouses, place of origin of women, income level, differ-

198 BMJ VOLUME 331 23 JULY 2005 bmj.com

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Table 2 Prevalence of spousal physical abuse, Tirana, Albania. Values are numbers (percentages) unless stated otherwise
Committed any physical No physical
violence in past year violence in past year Odds ratio

BMJ: first published as 10.1136/bmj.331.7510.197 on 21 July 2005. Downloaded from http://www.bmj.com/ on 9 July 2022 by guest. Protected by copyright.
Husband’s characteristic No* (n=384) (n=655) (95%CI) P value
Age (years)
46-69 456 152 (40.0) 304 (46.7) 1.00†
35-45 385 137 (36.1) 248 (38.1) 1.10 (0.83 to 1.47) 0.49
25-34 190 91 (23.9) 99 (15.2) 1.84 (1.30 to 2.60) <0.01
Education (years)
>12 226 74 (19.6) 152 (23.3) 1.00†
9-12 542 181 (48.0) 361 (55.3) 1.03 (0.74 to 1.43) 0.86
0-8 262 122 (32.4) 140 (21.4) 1.79 (1.24 to 2.59) <0.01
Employment status
White collar 253 100 (26.5) 153 (23.8) 1.00†
Blue collar 511 189 (50.1) 322 (50.0) 0.90 (0.66 to 1.22) 0.50
Unemployed 257 88 (23.3) 169 (26.2) 0.80 (0.56 to 1.14) 0.22
Religion
Christian 427 159 (41.6) 268 (41.0) 1.00†
Muslim 609 223 (58.4) 386 (59.0) 0.97 (0.75 to 1.26) 0.84
Origin
Urban area (Tirana or other) 517 149 (38.8) 368 (56.4) 1.00†
Rural area (came to city before age 10) 312 116 (30.2) 196 (30.0) 1.46 (1.08 to 1.97) 0.01
Rural area (came to city at age ≥10) 208 119 (31.0) 89 (13.6) 3.30 (2.36 to 4.61) <0.01
Constantly and violently jealous
No 725 257 (68.4) 468 (72.2) 1.00†
Yes 299 119 (31.6) 180 (27.8) 1.20 (0.91 to 1.59) 0.19
Drunk every day
No 911 333 (88.1) 578 (89.3) 1.00†
Yes 114 45 (11.9) 69 (10.7) 1.13 (0.76 to 1.69) 0.54
Childhood abuse
None 778 276 (73.8) 502 (77.8) 1.00†
Witnessed abuse of mother 59 24 (6.4) 35 (5.4) 1.25 (0.73 to 2.14) 0.42
Experienced physical abuse in childhood 110 41 (11.0) 69 (10.7) 1.08 (0.71 to 1.63) 0.71
Both 72 33 (8.8) 39 (6.0) 1.54 (0.95 to 2.50) 0.08
*Discrepancies in totals are due to missing values.
†Reference category.

ence in educational level between spouses, difference
in employment level between spouses, number of chil-
dren, number of household members, employment
status of men, male jealousy, alcohol misuse, and male
experience of abuse in childhood. Colinearity between
educational status of men and women and educational
discrepancy between spouses prevented all of these
being retained in one model. As all seemed to be
important in different ways, we built a second model
showing educational discrepancy, but not men’s and
women’s education level, otherwise using the same
backwards stepwise elimination procedure and candi-
date variables. The fit of the logistic regression models
was tested by likelihood ratio and Hoshmer-
Lemeshow goodness of fit tests. All statistical analyses
were done with SPSS 10.0 for Windows.
Results
The mean age of the women was 42.3 (median 41.0,
interquartile range 33.0-50.0) years, and their hus-
bands’ mean age was 46.6 (45.0, 37.0-55.0) years. Of the
women interviewed, 384 (37%) reported at least one
episode of spousal violence in the past year, and 267
(26%) reported three or more episodes (655 (63%)
reported none; 72 (7%) reported one episode, 45 (4%)
two, 97 (9%) three, 39 (4%) four, 104 (10%) five to nine,
27 (3%) 10 or more).
The prevalence of violence was highest among
women aged 25-34, those with more than 12 years of
education, those employed in white collar positions,
women who were more educated than their spouse, in
households where there were more children and more
household members, and in couples where the wife
was the only one employed (table 1).
Husbands who had been violent towards their
wives were more likely to be aged 25-34, to have less
than nine years of schooling, to have come from a rural
area (especially doing so at, or after, 10 years of age),
and to have witnessed their mothers being abused and
to have been beaten in childhood (table 2).
The multiple variable logistic regression model
(table 3) of factors associated with physical violence
showed greatest risk for the youngest women (aged
25-34). Risk increased with increasing educational level
for women, with decreasing educational level for men,
and with men being of rural origin and having left
rural areas at age 10 or later. Risk of violence reduced
with decreasing employment status of women: women
in blue collar work, housekeepers, and unemployed
women were at lower risk than those in white collar
occupations.
The model with educational discrepancy (table 3)
showed least risk of violence when women were
married to a more educated spouse. Women were pro-
tected (but less so) if their spouse had the same educa-
tional level, and they were most at risk if they were
more educated than their spouse. There was substan-
tial confounding between the educational discrepancy
variable and most factors in the first model. The only
variable that showed no change in effect size was men’s
rural origin. After adjustment for education discrep-

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ancy, women’s age was not independently associated

with risk of violence; women’s employment status was
What is already known about this topic
protective only if women were unemployed; and a vari- Intimate partner violence affects women

BMJ: first published as 10.1136/bmj.331.7510.197 on 21 July 2005. Downloaded from http://www.bmj.com/ on 9 July 2022 by guest. Protected by copyright.
able not in the first model, men’s employment status, is worldwide
seen in the model with increased risk associated with
men being unemployed (table 3). In most settings, the risk is greatest for the least
educationally and economically empowered
Discussion women or for those with middle levels of
empowerment
Spousal violence is highly prevalent in Tirana, and,
indeed, the prevalence of intimate partner violence in What this study adds
the past year is one of the highest reported The prevalence of physical violence in Albanian
internationally.1 Women with higher status (those best women is among the highest recorded in
educated, with higher status employment, and those population studies, and the risk was greatest for
more educated than their spouses) were most likely to women who were well educated, employed in high
report violence. Less powerful men (those less status occupations, and, particularly, more
educated and unemployed) were more likely to be vio- educated than their spouses
lent. Men who came from rural areas, especially those
who had lived in rural areas longer, were more likely to
be violent. Younger women were more likely to experi-
ence physical abuse seen among the women of Tirana, possibly because
These findings, related to women’s and men’s status, Albania is known to be a country with particularly con-
are in keeping with theories of causes of intimate servative ideas about sex roles.9 10
partner violence that argue that violence is used to The finding that men of rural origin were
enforce gender hierarchies and, particularly, when men independently at greater risk of abusing women than
have a sense of powerlessness because their social posi- those of urban origin has not been reported often.4 17 19
tion makes them feel “unsuccessful” as men.4 11–13 21 The explanation may be cultural or could be due to an
Research from other countries has often also shown that unmeasured confounder. In rural areas there may be
the most educationally and socially empowered women different norms about a man’s right to exert control
gain a level of protection.1 4 19 21 22 Such protection is not over his wife, and weaker sanctions against violent
behaviour. This might have been supported by
Table 3 Multiple variable logistic regression models of factors associated with spousal evidence that men from rural areas were more likely to
physical violence experienced by 945 married women in Tirana, Albania have witnessed abuse in childhood, but the level of
Model 1 (including educational Model 2 (including educational
reporting of this was so much lower than would have
level of women and men) discrepancy) been expected from the overall prevalence of spousal
Variable Odds ratio (95% CI) P value Odds ratio (95% CI) P value violence, and we suspect that the (third party)
Women reporting by women was unreliable.
Age (years): It is interesting to consider the extent to which
46-65 1.00 these findings have been influenced by the transition in
35-45 1.31 (0.92 to 1.88) 0.13 Albania. In the past 15 years, rapid movement of peo-
25-34 1.47 (1.04 to 2.09) 0.03
ple to cities has occurred, economic inequality has
Educational level:
increased, the position of women has changed (albeit
High 1.00
slowly), and unemployment has become very high.
Middle 0.45 (0.27 to 0.74) <0.01
Low 0.27 (0.15 to 0.49) <0.01
This has brought rapid changes to many Albanian
Employment status:
families, and many women are more independent and
White collar 1.00 1.00 have greater economic responsibility whereas men are
Blue collar 0.64 (0.41 to 1.00) 0.05 0.97 (0.52 to 1.80) 0.92 less able to fulfil their culturally expected roles as (fam-
Housekeepers 0.36 (0.14 to 0.96) 0.04 0.89 (0.52 to 1.50) 0.65 ily) protectors and providers.9 10 The tension this has
Unemployed 0.25 (0.10 to 0.63) <0.01 0.55 (0.36 to 0.86) 0.01 created may have led to an increase in intimate partner
Men violence, especially among the groups of women who
Educational level: have been in the forefront of these changes.
High 1.00 This study has some limitations. Under-reporting
Middle 1.90 (1.17 to 3.08) 0.01 of intimate partner violence in research is common,
Low 5.01 (2.91 to 8.64) <0.01
especially when exposure is assessed with one
Origin:
question.23 Sexual violence and emotional violence
Urban 1.00 1.00
were not measured. Lifetime exposure was not
Rural (before age 10) 1.43 (1.03 to 2.00) 0.03 1.39 (1.01 to 1.94) 0.05
measured, so we cannot discount the possibility that
Rural (until age 10 or 3.31 (2.29 to 4.80) <0.01 3.25 (2.25 to 4.69) <0.01
later) differences in prevalence between higher and lower
Educational discrepancy: status women were due to differences in duration of
Women more educated 1.00 violence in marriage. Some risk factors for violence,
Equal 0.40 (0.28 to 0.58) <0.01 such as alcohol consumption and relationship dynam-
Men more educated 0.21 (0.11 to 0.39) <0.01 ics or conflict, were not assessed comprehensively, and
Employment status: this may explain why they were not shown to be associ-
White collar 1.00 ated with violence in the final models. Relationships
Blue collar 1.27 (0.84 to 1.92) 0.26
found in one study of this nature cannot be assumed to
Unemployed 3.36 (1.41 to 8.00) 0.01
be causal.

200 BMJ VOLUME 331 23 JULY 2005 bmj.com


Conclusions
Intimate partner physical violence is highly prevalent
in transitional Albania. The most empowered women
are most likely to experience it and the least powerful
men are most likely to perpetrate it. Men of rural origin
are at increased risk of abusing their spouse in this
country, which has experienced considerable internal
migration in the past few years. Among the challenges
for post-communist Albania, and its health profession-
als, is the need to reduce the prevalence of intimate
partner violence, as well as to provide support for
women who are in, or have been in, violent
relationships and to be aware of the ways in which inti-
mate partner violence influences psychological and
physical health.
Contributors: GB and ER conceived the study and designed it
with the help of SJ and UL. GB and ER conducted the study in
Tirana. GB analysed the data and interpreted them with UL, VB,
and RJ. GB and RJ wrote the draft of the paper and all other
authors critically revised the draft of the paper for important
intellectual content. All authors approved the final version of
the manuscript. GB is guarantor.
Funding: Institute of Health Education and Human Welfare,
Lublin, Poland.
Competing interests: None declared.
Ethical approval: Albanian Committee of Medical Ethics.
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Development of family medicine in Kosovo
Robert N Hedley, Bajram Maxhuni
Many eastern European countries are expanding primary care. Experience in Kosovo shows how
some of the difficulties can be overcome
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evolution of primary care in Kosovo and the lessons
for other post-communist countries.
Development of health services
Before 1989 inpatient services in Kosovo operated
through six hospitals. Primary health care was
delivered through large clinics (health houses) in 29
municipalities that oversaw a network of small clinics
(ambulantas and punctas). The healthcare system relied
heavily on specialists. Primary healthcare services were
divided among subspecialties by age, sex, and disease
type and provided by general practitioners and nurses.
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BMJ VOLUME 331 23 JULY 2005 bmj.com
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secondary care. Private medical practice was not Hopwell House,
Hopwell,
permitted. Derbyshire
Most Kosovar Albanians were dismissed from DE72 3RU
management and senior positions in all public services Robert Hedley
adviser family
during 1990 to 1992. The Mother Theresa Society set medicine, Kosovo
up a parallel primary healthcare system with 96 clinics
Centre for the
throughout Kosovo, staffed and used by Albanian Development of
Kosovars. Private medical practice began to develop. A Family Medicine,
Pristina, Kosovo
parallel system of medical education was also set up in
Bajram Maxhuni
these clinics and in private houses. Kosovar family
At the end of the war in Kosovo in 1999, the WHO medicine programme
manager
assessed the health needs of Kosovo. The key
Correspondence to:
recommendation was to strengthen and reorganise R N Hedley
primary care.3 This principle was emphasised in the rnhedley@aol.com
Health Policy for Kosovo, 2001,4 which recommended
that patients should register with family doctors, with BMJ 2005;331:201–3
2000 patients to each doctor plus two nurses, and that
family doctors should also be personal doctors for first
contact, having preventive as well as curative duties and
acting as gatekeepers to secondary care.4
201